Original Article

Condylar hyperactivity: Diagnosis and

treatment - case reports
Maria Christina Thomé Pacheco*, Robson Almeida de Rezende**, Rossiene Motta Bertollo***,
Gabriela Mayrink Gonçalves****, Anita Sanches Matos Santos****

Abstract

Introduction: Condylar hyperactivity is a condition triggered by an imbalance in bone growth

factors, which causes facial asymmetry. It can be classified into three different types: hemiman-
dibular hyperplasia (HH), hemimandibular elongation (HE) and a hybrid form. It is essential
that a correct diagnosis of these hyperactivities be reached since each type of anomaly requires a
different approach. Treatment options include surgery and high condylectomy. Objectives: The
purpose of this article is to present two cases of facial asymmetry caused by condylar hyperac-
tivity, showing the importance of an accurate diagnosis and the means used to achieve it while
seeking an appropriate treatment for each case.
Keywords: Maxillomandibular anomalies. Facial asymmetry. Condylar hyperplasia.

introduction function with time. The volume of facial mus-

Skeletal asymmetries of the mandible caused cles remains unchanged. Other features include
by condylar hyperactivity can pose serious TMJ crepitation (crackling/popping sounds),
functional, esthetic and psychosocial problems limited mandibular movements (rotation, pro-
for patients. Although their etiology is still un- trusion and mouth opening), severe crossbite
known, some authors believe they can be caused and irregular condyle anatomy. Developmental
by trauma, inflammation, hypervascularity, ge- changes do not involve pain, symptoms usually
netic factors and hormonal disorder.4,7,11,13 remain unchanged over time, changes may oc-
Several classifications are available. Some are cur in the size or function of the facial muscles,
etiology-related while others divide these anom- no functional changes take place in the TMJ,
alies according to the growth factors involved in there may be limited protrusion without lim-
its development. Asymmetries can therefore be iting mandibular rotation movements, a pro-
acquired or developmental, and since each situ- nounced dental compensation in the asymmet-
ation presents with different features a differ- ric mandible may be present and the condyle
ential diagnosis can be more easily established. remains pronounced and smooth, even in the
Acquired asymmetries involve pain, symptom presence of volumetric changes.15
changes, alterations in facial appearance and According to Obwegeser and Makek,13 hy-

* PhD in Orthodontics, Federal University of Rio de Janeiro (UFRJ). Professor of Orthodontics, Federal University of Espírito Santo, Vitória, Espírito Santo State.
** MSc in Oral and Maxillofacial Surgery, PUC-RS. Professor of Oral and Maxillofacial Surgery I and Oromaxillofacial Prosthesis and Traumatology, Federal Uni-
versity of Espírito Santo.
*** MSc in Oral and Maxillofacial Surgery and Traumatology, PUC-RS. Substitute Professor of Oral and Maxillofacial Surgery II, Federal University of Espírito
Santo.
**** Dentistry graduate, Federal University of Espírito Santo.

Dental Press J Orthod 77 2010 July-Aug;15(4):77-83

Condylar hyperactivity: Diagnosis and treatment - case reports

peractivity can be classified into three different asymmetry development occurs it may cause
types: hemimandibular hyperplasia (HH), hemi- maxillary inclination in response to mandibu-
mandibular elongation (HE) and a hybrid form. lar growth.2 Otherwise, there will be unilat-
Many authors use the term condylar hyperplasia eral posterior open bite.13 The dental midline
to refer to these three forms, but this is not ap- is usually shifted to the malformed side. The
propriate, since it is only in HH and hybrid cases gonial angle is either normal or more acute16
that a true condylar hyperplasia is found. and, in general, a growth period elapses after
Condylar hyperactivity is common to these the patient’s asymmetric growth is completed.
three forms and occurs primarily due to an im- The hybrid form can produce the strang-
balance in the growth regulatory factors located est forms of facial and mandibular asymme-
in the cartilaginous layer of the condyle. One try. The condyle may have an increased bone
such factor is responsible for height growth mass, there may be a crossbite, chin deviation
(Factor L), and manifests itself in hemimandib- toward the opposite side and a vertical in-
ular elongation; the other factor is responsible crease in the affected hemimandible, creating
for bone mass growth (Factor M) and remains an oblique occlusal plane. Different signs will
active in hemimandibular hyperplasia.12 emerge depending on which growth factor is
Hemimandibular elongation may occur as an being activated. 12
extension of the condyle or ramus in the ver- It is important that clinicians learn to iden-
tical plane, or as an extension of the body in tify such hyperactivities because development
the horizontal plane. Combined vertical and time, dentoalveolar compensation and the like-
horizontal elongations are possible.9 Their main lihood of an intervention achieving success are
clinical feature are an elongation of one side different for each type of anomaly.9
of the mandible with no increase in bone mass Diagnosis must be based on anamnesis, an
production. Both the chin and the midline of evaluation of previous medical and dental his-
the lower teeth are shifted to the side opposite tory, clinical examination, model analysis, com-
to the elongation and, typically, a crossbite is plementary tests such as computed tomography
also present. The teeth on the affected side are and bone scintigraphy.6,14,16
usually in infra-occlusion when compared with The purpose of this article is to present two
the teeth on the opposite side.16 A flattening of cases of facial asymmetry caused by condylar
the gonial angle in the affected side can also be hyperactivity, showing the importance of an ac-
observed.9,12,16 Typically, elongation stabilizes curate diagnosis while seeking an appropriate
when patients cease to grow. treatment for each case.
Hemimandibular hyperplasia is character-
ized by a three-dimensional increase in the af- CASE REPORT
fected side of the mandible extending to the Case 1
symphysis region.2,12 Its major characteristics A female Caucasian patient, aged 17, sought
are: lower border of the mandible on the af- orthodontic treatment with the chief complaint
fected side positioned further down when of asymmetrical facial growth, which made her
compared with the contralateral side; increased different from her identical (monozygotic) twin
distance between tooth apices and mandibular sister. No history of trauma or asymmetry cases
canal.2,12 An inclination of the occlusal plane in the family were reported. She presented with a
and rima oris on the affected side can also be swelling in the left side of the mandible, chin de-
observed. Depending on the stage in which viation to the opposite side, posterior open bite on

Dental Press J Orthod 78 2010 July-Aug;15(4):77-83


the left side and inclined maxillary occlusal plane
(Fig 1). Radiographs showed a three-dimensional
increase of the hemimandible and an increase in
distance between root apices and mandibular ca-
nal (Figs 2, 3 and 4). Bone scintigraphy showed
active growth of the left condyle (Fig 5). Through
the association of clinical and imaging features we
FIGURE 1 - Initial facial appearance. FIGURE 2 - Initial radiographic appearance.
FIGURE 3 - Computed tomography showing size
differences between condyles.
ANTERIOR TO RIGHT SIDE
FIGURE 5 - Bone scintigraphy showing increased uptake in the left condyle.
Dental Press J Orthod
Pacheco MCT, Rezende RA, Bertollo RM, Gonçalves GM, Santos ASM
concluded that this was a case of condylar hyper-
activity of the hemimandibular hyperplasia type.
Treatment comprised presurgical orthodontic
preparation, orthognathic surgery (upper maxil-
lary repositioning and reduction of body, ramus
and gonial angle height) and high condylectomy
with external access.
FIGURE 4 - Three-dimensional reconstruction.
79 2010 July-Aug;15(4):77-83
Condylar hyperactivity: Diagnosis and treatment - case reports
Case 2
A male Caucasian patient, 16 years old, sought
dental care because of a facial asymmetry. He
had no history of trauma. Clinically, he showed a
mandibular deviation and lower midline shift to
the right side, inclined maxillary occlusal plane,
chin deviation and misalignment in a typical case
of hybrid form condylar hyperactivity (Fig 6).
FIGURE 6 - Initial facial appearance.
DISCUSSION
An accurate diagnosis of the different types
of anomalies is essential for a suitable treat-
ment plan. Besides clinical analysis and the use
of conventional radiographs, computed tomog-
raphy with three-dimensional reconstruction
(3D) allows for greater visualization of the skel-
eton and better assessment of the affected ar-
eas. Bone scintigraphy is an auxiliary diagnostic
method that makes it possible to detect diseases
or metabolic changes and has proven effective
in monitoring bone growth. It normally uses
Radiographs showed a volume increase in condy-
lar mass on the left side and increased distances
between root apices and mandibular canal (Fig
7). Treatment consisted of presurgical orthodon-
tic preparation, unilateral maxillary intrusion with
skeletal anchorage provided by a miniplate and,
at the final growth stage, mandibular orthognathic
surgery and genioplasty, without condyle removal.
FIGURE 7 - Initial radiographic appearance.
technetium pyrophosphate 99, which identifies
areas with increased osteoblastic activity.1,3 It is
noteworthy, however, that some procedures that
cause osteoblastic or osteoclastic activity, such
as dental extractions, can interfere with imaging
results.16 Therefore, one should always associate
imaging results with other clinical data.
The treatment of choice for condylar hyper-
activity is debatable and varies among different
authors. Patient age, clinical progress and sever-
ity of the deformity2 should be taken into ac-
count before treatment planning.
Dental Press J Orthod 80 2010 July-Aug;15(4):77-83

In the past, asymmetry treatment consisted
only of orthognathic surgery. However, relapse
occurred if condylar hyperactivity was still ac-
tive. Nowadays, thanks to the development of
new diagnostic techniques growth can be as-
sessed, and with it the risk of relapse, making it
possible to administer a more suitable therapy,
such as orthosurgical treatment and high condy-
lectomy when necessary.4
In case 1, the patient presented with max-
illary occlusal plane inclination and mandibu-
lar asymmetry. Given the fact that orthodontic
anchorage methods with the use of miniplates
for intrusion of maxillary segment were not yet
reported in the literature, the treatment con-
sisted of orthognathic surgery. A Le Fort I type
osteotomy was performed with gradual intru-
sion of the left side, leveling the maxillary oc-
clusal plane. In the mandible osteoplasty of the
body, ramus and gonial angle were performed
and since there was active growth in the left
side, a high condylectomy was chosen, thus re-
moving the growth center responsible for the
asymmetry (Figs 8, 9 and 10).
Different approaches can be adopted for
the treatment of condylar hyperactivity. Some
authors believe that high condylectomy should
be performed as soon as possible after diagnos-
ing hyperactivity and when there is a tendency
towards further development of asymmetry.
This would result in the removal of the center
responsible for hyperactivity, but the need may
arise for a second procedure to correct defor-
mities.12 Currently, it is known that the condyle
is a center of regional growth and not respon-
sible for the overall growth of the mandible.
An intervention in the condyle can therefore
be performed without causing major changes
in facial growth.5,10 Moreover, when condylec-
tomy is performed before the end of growth it
has the additional advantage of spontaneously
remodeling soft tissue and the condyle in the
articular fossa.2
Dental Press J Orthod
Pacheco MCT, Rezende RA, Bertollo RM, Gonçalves GM, Santos ASM
Some authors base their treatment choice on
patient age and asymmetry development speed.
In young patients with active hyperactivity they
usually perform a high condylectomy.2 However,
if asymmetry development is slow and does not
cause an unsightly facial appearance, treatment
should only be carried out after growth has ceased.
In adult patients whose growth is inactive the rec-
ommended therapy is orthognathic surgery, but if
condylar growth is active, condylectomy and or-
thognathic surgery are indicated. Other authors,
however, disagree.9 They believe that a longer
time period should elapse to allow for latent or
continuous hyperplasic growth to manifest.
Currently, complex cases such as the intru-
sion of posterior teeth8 can be resolved with the
aid of miniplates. These devices are installed
temporarily in the maxilla or mandible and af-
ford stable and effective skeletal anchorage, en-
abling the performance of orthodontic move-
ments17 and thereby restoring the occlusal level.
In case 2, as the patient’s maxilla was in-
volved, orthodontic anchorage was performed
with miniplates, which allowed the intrusion of
the posterior segment of the left maxilla (Figs
11 and 12). Thus, the maxillary occlusal plane
was aligned, setting the stage for a less invasive
surgical treatment plan and the correction of
asymmetry through intervention in the mandible
(vertical technique) and chin, for esthetic correc-
tion. No intervention was made in the condyles as
the bone scintigraphy performed preoperatively
showed symmetrical uptake in the condyles,
showing that there was no hyperactivity but only
the patient’s normal growth (Figs 13 and 14).
The two cases demonstrate different behaviors
in the timing and form of intervention as new
techniques emerged, allowing the administration
of less invasive treatments. Satisfactory results
were achieved even with different approaches,
i.e., occlusal stability was gained and maintained
during a monitoring period of four years in case
1 and one year in case 2.
81 2010 July-Aug;15(4):77-83
Condylar hyperactivity: Diagnosis and treatment - case reports

FIGURE 8 - Postoperative facial ap- FIGURE 9 - Postoperative radiograph showing a FIGURE 10 - Postoperative panoramic radiograph.
pearance. remodeled left condyle.

FIGURE 11 - Preoperative facial appearance af- FIGURE 13 - Postoperative facial appearance.

ter leveling of upper occlusal plane.

FIGURE 12 - Panoramic radiograph showing leveling of upper occlusal FIGURE 14 - Postoperative panoramic radiograph.
plane with the use of miniplates.

Dental Press J Orthod 82 2010 July-Aug;15(4):77-83


CONCLUSIONS
Facial asymmetries caused by condylar hy-
peractivity can cause considerable inconve-
nience to patients. Early diagnosis and the estab-
lishment of an appropriate therapy is of utmost
importance to avoid development of secondary
deformities, which would render the treatment
more complex. Therefore, we must conduct a
proper clinical examination as well as comple-
mentary examinations such as radiography, 3D
computed tomography and bone scintigraphy.
After diagnosis, an appropriate treatment
must take into account patient age, deformity
development rate, whether or not hyperactivity
is present, asymmetry severity level and func-
tional constraints. Only then, the best possible
procedure should be selected
Dental Press J Orthod
Pacheco MCT, Rezende RA, Bertollo RM, Gonçalves GM, Santos ASM
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Submitted: August 2008
Revised and accepted: June 2009
Contact address
Anita Sanches Matos Santos
Rua Tupinambás, 255, ap. 401 – Jardim da Penha
CEP: 29.060-810 – Vitória/ES, Brazil
E-mail: anitasms@gmail.com
83 2010 July-Aug;15(4):77-83